Vision Therapy: An Update
Authors: Donna Clemens, VI Education Specialist, TSBVI Outreach Program
Keywords: vision therapy, VT, dyslexia, learning disability, orthoptic vision therapy, behavioral vision therapy, perceptual vision therapy, ARD, IEP Committee, ADD, ADHD
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In 2018, Dr. Kitra Gray wrote “Controversies Surrounding Vision Therapy” for TX SenseAbilities. During the almost four years since that article was written, parents, guardians and professionals have continued to receive recommendations for and about vision therapy that are, as Dr. Gray described, vague, inconsistent, emotional, and conflicting (Gray, 2018).
The delivery of services for a student with a visual impairment in Texas is determined by standards of practice and governmental policies such as the Texas Administrative Code, (19 T.A.C. §89.1040 (12)), the Texas Education Code (T.E.C. §30.002), and the Code of Federal Regulations (34 C.F.R. §300.8(c)(13)). Once it is determined that a student meets eligibility requirements as visually impaired (VI), parents and guardians work with other members of the student’s educational team to provide identified services in both home and school settings.
The issue of student eligibility is one that may be best addressed in a different and more detailed article. Specific information about VI eligibility criteria in Texas can be found in the Guidance Document for VI Eligibility provided by TEA (Texas Education Agency) and TxSSN (the Texas Sensory Support Network). For the purposes of this article, once eligibility as a student with a visual impairment has been determined by the student’s ARD (Admission, Review, and Dismissal) committee (also known as an IEP Committee), services based on the student’s academic/educational needs can begin (Office of Special Education and Rehabilitation Services [OSEP], 2014). The issue of vision therapy, however, continues to be surrounded by mystery, controversy, and vague responses regarding how and what it can do for students.
Here is what is currently known about vision therapy: vision therapy is an individualized medical program of treatment focused on the overall function and performance of the eye. VT is prescribed by medical professionals, not educational staff, and is divided into three areas, as described by the American Association for Pediatric Ophthalmology and Strabismus (AAPOS):
- Orthoptic vision therapy
- Vision therapy for the correction or prevention of nearsightedness (myopia)
- Behavioral/perceptual vision therapy
Two burning questions remain: does vision therapy work in any of these three subcategories, and will it help with learning disabilities (LD) and dyslexia? The information below attempts to answer these questions and also provides suggestions for parents, guardians, and professionals when their students are referred for VT.
Orthoptic Vision Therapy
Orthoptics is a term that means “straightening the eyes.” Orthoptic therapy consists of weekly eye exercises that should be performed over several months in an optometrist’s office and/or at home. These exercises are aimed at measuring, managing, and improving eye deviations that are small, intermittent, and symptomatic, such as those in amblyopia (AAPOS, 2020). Studies of vision therapy continue to explore if there are areas that can be improved when this structured approach is employed. The website of Boston Children’s Hospital acknowledges that there is disagreement among professionals about the validity of vision therapy and that “solid research findings are hard to come by” (Vision Therapy, n.d.). Toward this end, Boston Children’s began offering vision therapy as an option for patients with certain kinds of eye problems while also providing a way to study the effectiveness of vision therapy. An example of the effectiveness of vision therapy can be found in a conclusion of the American Association for Pediatric Ophthalmology and Strabismus that “Orthoptic eye exercises as prescribed by pediatric ophthalmologists, orthoptists, and optometrists can be beneficial in the treatment of symptomatic convergence insufficiency.” (AAPOS, 2020).
While the website of Boston Children’s Hospital agrees that vision therapy may be successful for certain types of vision problems, they nevertheless state that “Vision therapy is not endorsed as an effective or scientifically validated therapy by ophthalmologists or pediatricians.” As stated earlier in this article, the issue of vision therapy continues to be vague, inconsistent, emotional, and conflicting (Gray, 2018).
Vision Therapy to Address Nearsightedness, Learning Disabilities (LD), and Dyslexia
Vision therapy has been prescribed to address nearsightedness (myopia), LD and dyslexia. Myopia is a common condition where people can see more clearly at a nearer distance. Some reports indicate that activities such as computer or tablet use and close reading have contributed to an increase in myopia in students. Very structured VT exercises may be recommended to increase functioning, but these cases tend to be very particular and narrow in scope. There is little data to indicate that VT can treat all patients with myopia and see improvement (AAPOS, 2020).
Learning disabilities and dyslexia, which are sometimes referred to as “hidden disabilities” by VT practitioners, may present like attention-deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD). They are not, however, actual visual conditions as reported by the College of Optometrists in Vision Development (COVD, 2021). In the past, theories linked dyslexia to defects in the visual systems, but current understanding does not support these previous theories (Handler & Fierson, 2009). Studies have proven, for example, that skipping words is a symptom of dyslexia, not a cause, or it may be a result of linguistic deviation, not visual or perceptual disorders (AAPOS, 2020). The research that supports the use of visual therapy has often been conducted or purchased by VT clinics for their use, which leads to questions regarding the reliability of these studies. The American Academy of Pediatrics states that “Detailed review of the literature supporting vision therapy reveals that most of the information is poorly validated, because it relies on anecdotes, poorly designed studies, and poorly controlled or uncontrolled studies.” (Handler & Fierson, 2009). Even though there are continued claims based on this possibly biased research of a connection between VT and reading disorders, independent studies show no causal relationship between them (Katz, 2022).
Behavioral/Perceptual Vision Therapy
Behavioral/Perceptual Vision Therapy consists of eye exercises that are reported to improve visual processing and visual perception. Behavioral vision therapy is proposed to address visual attention and mental focus (concentration) that could cause difficulty with shifting or the ability to sustain visual focus (AAPOS, 2020). This broad treatment definition allows for a very loose referral of patients with various conditions.
Visual perception is the manner in which surroundings, colors, patterns, and structures are processed by the brain. The brain usually picks up the general shape of something first. It then interprets patterns and identifies possible inconsistencies. The final step in visual perception is processing details and committing elements to memory. In other words, visual perception is the brain’s interpretation of what the eye sees.
Behavioral/Perceptual Vision Therapy purports to improve the visual functioning of the patient with structured behavioral and eye exercises. The American Academy of Pediatrics does not support this approach, however, asserting that “Scientific evidence does not support the efficacy of eye exercises, behavioral vision therapy, or special tinted filters or lenses for improving the long-term educational performance in these complex pediatric neurocognitive conditions.” (Handler & Fierson, 2009). They repeatedly state in “Learning Disabilities, Dyslexia and Vision” that the claim that vision therapy improves visual efficiency cannot be substantiated,” and conclude that “Diagnostic and treatment approaches that lack scientific evidence of efficacy are not endorsed or recommended.” (Handler & Fierson, 2009).
Considerations When VT is Recommended
If vision therapy is recommended for a student, the first step should be to seek a second opinion, specifically with an ophthalmologist with pediatric experience. If a child has a learning disability and VT is recommended as a treatment for that disability, it will be important to request research that is not associated with a VT clinic that supports the efficacy of VT as a treatment for learning disabilities. As noted above, scientific research does not support the assertion that eye exercises will improve performance over the long term for students with these conditions.
If a child has or is suspected of having a vision problem that could affect their academic or educational performance, a referral for evaluation by the school’s vision team should be pursued. If a learning disability or dyslexia is suspected, a referral to the school’s academic team, where school specialists can evaluate and provide needed interventions promptly, is vital. Parents and guardians should be aware of the different types of services provided by school districts, including those provided by a Certified Teacher of Students with Visual Impairments (TVI). Specific information about the roles and responsibilities of TVIs can be found in Dr. Gray’s article and in Guidelines and Standards for Educating Students with Visual Impairments in Texas (2020). It is important to recognize that these services are different from those provided by someone offering vision therapy. As described above, VT may be based on unreliable research and may thus hinder the provision of appropriate intervention. The American Academy of Pediatrics states that, “Ineffective, controversial methods of treatment such as vision therapy may give parents and teachers a false sense of security that a child’s learning difficulties are being addressed, may waste family and/or school resources, and may delay proper instruction or remediation” (Handler & Fierson, 2009). Being fully and carefully informed is the key to understanding vision therapy and to providing the most appropriate services to students.
American Association for Pediatric Ophthalmology and Strabismus. (2020, December). Vision therapy. American association for pediatric ophthalmology and strabismus. Retrieved August 20, 2022 from https://aapos.org/glossary/vision-therapy
Code of Federal Regulations (34 C.F.R. §300.8(c)(13)). Child with a disability. https://ecfr.io/Title-34/Section-300.8
What is vision therapy? (2021). College of Optometrists in Vision Development (COVD). Retrieved May 10, 2021 from https://www.covd.org/page/vision_therapy
Education For Children with Visual Impairments. T.E.C. §30.002. (2019).
Eligibility Criteria. 19 T.A.C. §89.1040 (12). (2022).
Gray, K. (2018). Controversies surrounding vision therapy. TX SenseAbilities, TSBVI. https://www.tsbvi.edu/tx-senseabilities/issues/summer-2018/controversies-surrounding-vision-therapy
Guidelines and Standards for Educating Students with Visual Impairments in Texas (2020). Retrieved August 2022 from https://www.tsbvi.edu/statewide-resources/professional-development/publications/guidelines-standards
Handler, S. & Fierson, W. M. (2009, August 1). Learning disabilities, dyslexia, and vision. American Academy of Pediatrics, 124(2), 837–844. Retrieved August 2022 from https://doi.org/10.1542/peds.2009-1445
Katz, L. A. (2022). The eyes still don’t have it. Retrieved August, 2022 from http://dyslexiahelp.umich.edu/answers/eyes-still-dont-have-it
Office of Special Education and Rehabilitation Services. (2014). OSEP Kotler response letter [Legal response letter]. http://fw.esc18.net/FrameworkAuthoringSystem/Documents/AdditionalResources/OSEP%20Ltr%20to%20Kolter%2011.12.14.pdf
Texas Education Agency. (2021, November 30). Guidance documents: Students with visual impairments: Eligibility for special education. Texas Sensory Support Network https://www.txssn.org/domain/255
Texas Education Agency. (2022, June). Texas administrative code: Commissioner’s rules concerning special education services (§89.AA. Chapter 89): Adaptations for special populations https://tea.texas.gov/sites/default/files/ch089aa.pdf
Texas Education Code: Section 30.002 (2019). Education for children with visual impairments https://texas.public.law/statutes/tex._educ._code_section_30.002
Visual processing disorders. (n.d.). Retrieved on June 2, 2022 from https://mindwell.us/visual-processing-disorders/#:~:text=A%20visual%20processing%2C%20or%20perceptual,or%20processed%20by%20the%20brain
Vision therapy. (n.d.). Boston Children’s Hospital. Retrieved August, 2022 from https://www.childrenshospital.org/treatments/vision-therapy#in-depth